Provider Demographics
NPI:1316068836
Name:PETTER, LINDA MARIE (DO)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:PETTER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 10TH ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4045
Mailing Address - Country:US
Mailing Address - Phone:253-351-5300
Mailing Address - Fax:253-383-0161
Practice Address - Street 1:205 10TH ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4045
Practice Address - Country:US
Practice Address - Phone:253-351-5300
Practice Address - Fax:253-383-0161
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2049440Medicaid
WA91-0870154OtherTIN